Healthcare Provider Details

I. General information

NPI: 1730472796
Provider Name (Legal Business Name): MATTHEW ALLAN MCNEAL CRNA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/24/2011
Last Update Date: 02/01/2023
Certification Date: 02/01/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4701 MONTGOMERY BLVD NE
ALBUQUERQUE NM
87109-1219
US

IV. Provider business mailing address

104 TARGHETTA RD
CORRALES NM
87048-6937
US

V. Phone/Fax

Practice location:
  • Phone: 505-270-0876
  • Fax:
Mailing address:
  • Phone: 505-270-8760
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License NumberCRNA-01489
License Number StateNM
# 2
Primary TaxonomyN
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License NumberRN152361
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: